Provider Demographics
NPI:1497076475
Name:TANENBAUM MANSSON, ALEXIS (LISW-CP)
Entity Type:Individual
Prefix:MS
First Name:ALEXIS
Middle Name:
Last Name:TANENBAUM MANSSON
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:ALEXIS
Other - Middle Name:TANENBAUM
Other - Last Name:MANSSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:728 INLET DRIVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-4905
Mailing Address - Country:US
Mailing Address - Phone:843-991-7872
Mailing Address - Fax:
Practice Address - Street 1:728 INLET DR
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-4905
Practice Address - Country:US
Practice Address - Phone:843-991-7872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-14
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC88601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical